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NEW YORK STATE SCHEDULE OPWDD-1 SCHEDULE OF SERVICES ICF/DDs Only Page CONSOLIDATED FISCAL REPORT For the Period January 1 2010 to December 31 2010 AGENCY NAME SITE ADDRESS AGENCY CODE PROGRAM TYPE CODE NUMBER MEDICAID PROVIDER AGREEMENT NUMBER OPERATING CERTIFICATE NUMBER Complete a separate schedule for each site. Line No. SERVICE TYPE Pharmacy Services Col. 1 Exclusively Purchased w/ Medicaid Card Col. 2 by ICF Col. 3 ICF Purchases Made Only Where MA Card Did Not Cover Items Col. 4 Amount...
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If col stands for 'information collection'.
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